Re: Who doses the patient?

[carol marcus <csmarcus@ucla.edu>]

At 10:32 AM 2/4/99 -0600, you wrote:
>Hi all,
>
>I would like to have your feed back on therapeutic NaI131 nuclear medicine
>procedure. It is not in the NRC regulations that the physician has to dose the
>patient even with 150 mCi of NaI131.  Is your NM physician present during the
>administration of NaI131 for the treatment of hyperthyroid or cancer
>treatment?
>
>Sincerely,
>
>Hoang Nguyen, DABR (medphydia@aol.com)
>RSO St Luke's Hospital Bethlehem
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>Dear Radsafer:

The NRC regulations do not require the presence of the Authorized User
Physician during any Nuclear Medicine therapeutic procedure.  In the State
of California, however, this has been a requirement for probably over ten
years.  With this requirement, California has virtually wiped out I-131
misadministrations.  I know of three that happened duing this period, and in
two cases the Authorized  User physicians had ignored the requirement and
were not present. In the third case, the diagnostic radiologist stood there
like a jerk, taking orders from his tech, instead of vice versa, because the
diagnostic radiologist was incompetent in therapy Nuclear Medicine.  He
could not even take care of the patient after his mistake; I actually helped
with the patient's care. (You can thank NRC for its lax requirements for
training and experience for Nuclear Medicine therapy and its pressure on
Agreement States for compatibility in this regard.  Even though the NAS-IOM
recommended INCREASED qualifications for Nuclear Medicine therapy, NRC is
now DECREASING qualifications even more.) Anyway, California never
instituted NRC's illogical "Quality Management" Rule (based on
purposely-concocted fraudulent data, which in addition has nothing to do
with "quality" or "management", and never decreased mistakes), because by
putting the physician in the room, mistakes made by nurses, clerks, primary
care docs, and techs were generally caught in time.

Consider the fact that California is responsible for about 20% of the
Nuclear Medicine in this country.  In the past 6 years, there has been ONE
I-131 misadministration, caused by a physician NOT board certified in
Nuclear Medicine who was NOT physically present when the dose was
administered.  When you compare this with NRC licensees, who HAVE the
pointless "Quality Management" rule, and correct for the total number of
procedures (actually, all NRC licensee procedures combined are probably not
much more than California's procedures), you can see how splendidly
California is doing relative to NRC.  While NRC was told over and over again
by its ACMUI that the way to stop mistakes was not the "Q/M" rule, but by
increasing qualifications for Authorized Users for Nuclear Medicine therapy
and by considering the usefulness of California's approach of requiring the
Authorized Users to be physically present, NRC of course paid no intention.
It is painfully obvious that it was never NRC's intention to stop mistakes.
It was NRC's intention to CREATE mistakes and shriek about them to Congress
and to the public in order to give the false illusion that the United States
has some use for NRC's incompetent and destructive non-medical "Medical"
Program.

Another intelligent aspect of California's program that NRC fails to
comprehend is that in California, ALL Nuclear Medicine technologists must be
certified.  While this may not work in some states with sparse population,
it would certainly work in most states and in some portions of the sparsely
populated ones. This also decreases the probability of mistakes.

However, in my opinion, the best way to insure good quality and safe
practice is to have a competent physician, usually a board-certified Nuclear
Medicine physician, planning therapy and being physically present when the
dose is administered. This is important for other than radiation protection
and mistake avoidance reasons.  The patient may have inadvertently begun a
medicine that would interfere with I-131 uptake and therapeutic action.  The
patient might need to be on a beta blocker, and for some reason may not have
been started on one.  The patient may have questions about adverse reactions
of therapy, and the physician should describe these along with appropriate
treatment should they occur.  Often the patient's family is there, or at
least a family member, and they have questions about radiation safety. There
are other issues for patients receiving metastron, quadramet, P-32 sodium or
chromic phosphate, or I-131 labeled antibodies.   There are issues of long
term medication and a follow-up plan.  Only the physician can take care of
these situations.

Ciao, Carol

<csmarcus@ucla.edu>

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